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Hoosier Valley Central School District 5187534458 HEALTH CERTIFICATE / APPRAISAL FORM Name: Date of Birth: School: M F Gender: Immunization record attached No immunizations given today Immunizations
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Mark the box or check the appropriate option that indicates that no immunizations were given on the specified day.
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If there is a space provided, write the date when no immunizations were given.
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Who needs no immunizations given today?

01
Individuals who have not received any immunizations on the specified day.
02
People who may have missed their scheduled immunizations or those who are not due for any immunizations at that particular time.
03
Individuals who have completed their immunization schedule and no additional vaccines are required on that day.
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No immunizations given today refers to a report filed when a patient did not receive any immunizations on a specific day.
Healthcare providers or facilities responsible for immunization records are required to file the report when necessary.
The report can be filled out either electronically or manually, providing details such as patient information, date, and reason for not receiving immunizations.
The purpose is to accurately document when a patient did not receive any immunizations on a particular day, ensuring proper record-keeping.
Patient details, date, and the reason for not receiving immunizations must be reported.
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